Provider Demographics
NPI:1154872372
Name:EVOLVE GROWTH INITIATIVES LLC
Entity type:Organization
Organization Name:EVOLVE GROWTH INITIATIVES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-361-9705
Mailing Address - Street 1:300 N PACIFIC COAST HWY STE 2060
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-4479
Mailing Address - Country:US
Mailing Address - Phone:772-361-9705
Mailing Address - Fax:
Practice Address - Street 1:6425 CHESEBRO ROAD
Practice Address - Street 2:
Practice Address - City:AGOURA
Practice Address - State:CA
Practice Address - Zip Code:91301
Practice Address - Country:US
Practice Address - Phone:424-281-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA198209044OtherSTATE LICENSE
CA05D2126813OtherCLIA